Monday, March 21, 2011

CRDTS!

It's over...hopefully.

Barring some unforseen miscalculation or hidden blunder, I believe I have officially passed the final test required to legally practice dentistry in the state of Illinois. Rumor has it, the grades should be posted sometime this week, so we shall see.

So how did it go?

Started rough, but honestly, I think the day in general went VERY smoothly. EVERY one of my patients showed up 15 minutes early. I cannot emphasize enough how important this is. Find the perfect patient, not the perfect case. If they show up late or are unruly or just a PIA to work on, you will be stressing terribly. Secondly, get an assistant you are familiar with. Their importance goes far beyond just suctioning and gopher running. They need to keep you calm and focused, treat it it like a normal day....even though we all know the day isn't normal at all.

So let me break it down:Wake up a 6am. At the school by 7am. Gather all my crap from the locker (forms, loupes, goggles, etc) and begin wrapping my unit. I walk out to check out my instruments for the first procedure around 7:30 and see my first patient already sitting in the waiting area...big sigh of relief.

My first procedure of the day was my class II amalgam, also the most technically demanding procedure of the day due to the less-than-ideal case selection. Basically you want a class II with caries just barely tapping the dentin (that perfect little triangle from all the D-1 lectures). You want good occlusion, and you don't want their to be an adjacent filling.

Well, my class II was a good millimeter past the DEJ with caries which already scares me because radiographs tend to underestimate the extent of decay. There was also a big bulky adjacent amaglam restoration to contend with. So while not ideal, this still is not a difficult procedure. What makes these procedures difficult for the day is the ENORMOUS amount of pressure you have to, putting it mildly, not fuck up.

My assistant showed up at 7:30 as well. I actually hired a real dental assistant from one of my rotation sites. More expensive than a D-2, but I felt comfortable working with him and knew that he would keep me focused while maintaing a sense of levity that helps SO MUCH when you are stressing.

So we seat my patient and get all the forms ready to go by 8:00. All the examiners come in and it is a mad house of students rushing to get the start check. By about 8:15 I'm set, the case gets approved, and I'm off to races...or am I?

It is now 8:45 and I still have not gotten the rubber dam on. I'm doing #3 MO, so I'm trying to clamp #2. This tooth is bulbous and I try about 12 different clamps. None will stay on long enough to withstand any sort of dam stretching. I can feel my face flushing, the sweat beading, thinking oh crap, I'm never going to get this damn thing on (pun intended).

Eventually, the practical voice inside of me says "Hey, remember you don't actually need the dam on for your prepration, just put it on #3 for the prep-check." Good job practical me.

I quickly cast my clamps and dams aside and just started preparing the tooth. Now here comes the next debatable topic. Modifications. I am of the thought group that if you aren't going to pulp-out, don't ask for a mod. You waste about 20-30 minutes per request. And believe you me, this exam may seem like you have lots of time...but you most certainly don't. With a minimum of 6 examiner checks a good 3-4 out of your 9 hours are spent waiting around. Add another 1-2 hours seating patients/eating something/administering anesthetic/breaking down/setting up/etc. You can run out of time fast.

So my thought, don't get the mods. Yea you will lose points for overextending, you may even get a substandard or two in there. WHO CARES, you fail if you run out of time. Case in point, my class II preparation was bigger than ideal. I chased stain and caries further than is ideal. But I got it all out and the prep didn't look bad at all from a realistic standpoint. Was I in failing range for overextension (2.5mm beyond DEJ)? Don't think so. Again, I haven't gotten the scores so maybe this choice to not mod will backfire, but I still feel like it was the right choice.

The dam is applied easily by clamping #3 and I send him off for a preparation check around 9:30. Now here is by far the worst part of this exam. Waiting for something to get graded. Oh my. It takes a good 30 minutes each trip and I felt my pulse just skyrocket each and every time. I literally couldn't just sit, I had to pace around, constantly doing laps around the clinic.

My assitant brings him back and gives me the thumbs up from far away, good news. I remove the rubber dam, place my matrix/wedge and fill 'er up with amalgam. The contour was awesome, the anatomy mehish but not terrible, but my contact was too damn tight. The adjacent restoration just had a HUGE broad contact area to work with so it was tough to get perfect. Floss was passing, but not as easily as I would have liked. This may be a sub or simply an acceptable..depends on the mood of the evaluator. The occlusion was mondo high, but I brought it down with round burs to an acceptable level. I sent it off around 10:30 and let my second patient know we'd be ready in 45 minutes (he also showed up early). So again, waiting is the worst part. Patient comes back with no instructions. I thank him profusely and send him on his way.

Class II thoughts:Wasted a lot of time with the damn damOverextended pretty much everywhere without requesting a mod (hoping the point deduction doesn't ruin me)Prep didn't look half-badFill was nice overall with a slightly too heavy contact.As you will shortly see, if I fail anything, I think it will be this.

My second patient is for the deep-cleaning. By the time he is seated with all forms completed it is about 11:15. So I send him off to get my treatment selection approved. The difference between perio and restorative on this exam is that you need to physically send your patient to the examiner station before you start perio. For restorative you only need a floor examiner to sign your sheet.

So believe it or not, it takes about 45 minutes for them to see and approve my treatment selection. Thankfully, I truly lucked out and got a PERFECT patient in terms of case simplicity. He had lots of calculus, but it was fairly light and not too difficult to remove. I was finished around 12:45. Now I may have missed the distal of #2 a little, but overall, I think this was one of the best SRPs I have ever completed in terms of results and speed. Now watch me somehow fail perio. Hopefully not!

Perio thoughts:Great case selection helpedCompliant patient who could keep his mouth open HUGE for long periods of timeFeel like I smoothed pretty much all of the surfaces (maybe missed 1-2 sites)Feeling pretty confident...but again..until those grades come up...

It is now 1:30, I go talk to my third patient (who has also arrived early!) and let him know we will be ready around 2:00. Could have gone around 1:45 but decided to wolf down a few power bars/drinks with my assistant. I had been too nervous to eat in the morning and hadn't had anything since 8:00pm the previous night...ugh.

After the quick breather we get my third and final patient (class III ML #8) seated and all paperwork cranked out. Now when we talk ideal case, this is about as good as it gets. Radiographically you can't see anything, but there is definitely a small shadow viewed clinically. I get the case approved and finish the prep around 2:30. Comes back with no instructions..I'm on the home stretch. Here is when the final terror ensues. I placed the composite and contour is great, but there it no/extremely light contact. How is this even possible? I didn't have to break the incisal contact during my preparation and didn't wedge the teeth either (for fear of displacement). The problem was that he has some serious perio (which is currently being treated). So his incisors exhibit a bit more mobility than most. So I tried wedging the distals of #8 and #9. Definitely got contact...but it would immediately vanish as I removed the wedges.

After some brainstorming, I finally end up removing some of the composite, rebond, and place new composite WITHOUT a mylar strip. This seemed to do the trick as I got that perfect little click when flossing the contact. I removed the flash/excess, polished quickly and send him off at 3:45 for the FINAL CHECK. As fate would have it, this final check was also the LONGEST.

The patient came back with no instructions around 4:25. DONE! DONE! DONE!

I immediately got all my stuff turned in and fled the scene.

Needless to say, the day lived up to my expectations in terms of sheer stress. And this was with things going relatively well, I feel terribly for my classmates that got screwed over in any way, shape, or form during this outdated and restrictive exam. The only final note I will add because I'm getting tired of typing is that all of the floor examiners were extremely nice. I was so worried they were going to be a bunch of hard-asses constantly nitpicking and docking us infection control points. Not at all. They would chat with us during waits and in general, were just unbelievably friendly. So that definitely helped relieve some of the stress.

Now back to enjoying spring break and praying that they post these scores ASAP so I can let out one final sigh of relief.